Call last weekend was one of the wildest days of my career to date, including some events that I’m literally not thinking about because, despite my predilection for seeing how close to the edge of a cliff I can get without falling over, I don’t dare to examine those events in detail. And that was only the beginning.
The last consult of the day was for an elderly patient with peritonitis. She had multiple other comorbidities, making the idea of operating on her quite daunting. Nevertheless, as I’ve told the medical students many times, if somebody honestly has peritonitis, then they need surgery. So I had to explain to the family, who thought they’d come in to the hospital for just another bout of the stomach flu. The altered mental status, clammy skin, absent urine output and glazed eyes didn’t have the same instant significance for them that they had for me.
Once they agreed that, despite the risks, they would rather take the risk of death with surgery than the certainty of death without surgery, I had some more calls to make: the senior resident, to come in from home. The OR, who suggested that they had other cases running and perhaps we could wait a couple hours; which returns to the principle that real peritonitis means surgery right now if physically possible, even if that means calling staff in from home. (Perhaps it comes from so many years listening to my father the anesthesiologist making call after call trying to arrange anesthesia and nursing coverage for night and weekend ORs; I haven’t quite adjusted to being the surgeon, the one who declares that it needs to be done, and then leaves it to the OR team to figure out how to make it happen. Not to be authoritarian, but someone has to be the one to say that an emergency is an emergency.) And the attending, one of the older ones, who believes in rattling the juniors at all opportunities. He drilled me with questions (all the labs; the medical history for the last two weeks; recent imaging; why didn’t we do this or that test); and above all, are you really sure that this sick old lady has peritonitis – so sure that you’re going to put her through the risk of an operation. I stood up to him, but by the time he hung up, I was very glad to see the senior resident arriving, and equally impressed by the patient’s physical exam.
She did well – much better than I expected. She’s already extubated, ready to start eating, and looking ten times better than that night (when she was nearly ready to be intubated simply for respiratory distress, by the time we got to the OR).
That was the first time I’ve made a hard call on a patient needing surgery. Deciding that a patient with a moderate small bowel obstruction can have an NG tube and be observed for twelve hours, or that a child with a good story and a good exam has appendicitis, that a patient with a cold, ischemic leg needs intervention, or that someone with a perforated ulcer needs surgery – those aren’t hard; they’re cut and dried. This patient wasn’t straightforward at all. I was the senior surgery person in the hospital, and I dragged everyone in from home, and forced the family to make a difficult decision, based on my clinical assessment. I’m sure this story is not that impressive to any experienced doctors who may be reading, but it was new for me.
And next month I get to do that every single night. . .
February 3, 2009 at 9:37 pm
Go Alice! Those are the kinds of days that make it all worthwhile.
February 4, 2009 at 7:31 am
Great Post,
what did you find once you got in?? I’m thinkin ischemic/dead bowel, maybe a perforated diverticulum…don’t see perforated ulcers as much since they put PPIs in the tap water…maybe a ruptured gall bag?
Frank
February 4, 2009 at 8:29 am
Good work, Alice!
February 4, 2009 at 5:07 pm
I know I am not a doc but I got the thrill of what that must have been like from reading your post.
I get that same sort of feeling when I go with an impression of a patient and maybe bypass a local hospital to go to a more specialist one and then later find out that my diagnosis was right.
Well done on moving along your own learning and confidence curve.
February 5, 2009 at 8:06 pm
Frank – Toxic megacolon from ulcerative colitis (which one can often temporize with medical management if it’s not completely toxic, which is why the attending was so skeptical). Although there are two of my attendings who seem to specialize in perforated gastric/duodenal ulcers, and encounter a few every month on a weekend night.